Patient Safety in Anesthesia...A success story

December 7, 1941  Pearl Harbor.... Lots of casualties. Patient safety routine efforts primarily consist of finger on the pulse, eyes on the chest, observation of skin color. The recently released drug, thiopental, is employed. Some of the soldiers die…of anesthesia (1-3). Anesthesia-related death rate reported at 1 in 450 (2).

September 1979 – September 1981 (WAK residency time). The operating surgeon calmly notes blood’s dark.  WAK’s reaction: BLOOD'S DARK!!! Dr. Todres says the first 3 things to check for with any problem in the OR is, first airway, then the airway, and finally the airway. So he checks it and finds a disconnect which somehow was not able to be heard with the esophageal stethoscope over the orthopedists’ hammers and drills. No oxygen analyzer, no disconnect alarm, no pulse oximeter, no automated blood pressure monitor; by today’s standards, no nothing, although we did have manual blood pressure cuffs, EKG machines,  and the beginnings of advanced hemodynamic monitoring. WAK’s attendings were fond of saying “when I was a resident…” followed by some parable of how he managed with no monitors other than his five senses.  It seemed like at least once a year at M&M there was discussion about an intraoperative death by undetected disconnect. Anesthesia death rate said to be about 1 in 10,000.

 

2007. Cyanosis is virtually never seen by trainees and death by disconnect is now  unheard of. Gas analyzers, pulse oximetry, end-tidal CO₂, easily balanced pressure monitors, idiot proof machines and more are part of the modern anesthesia tool box. Anesthesia death rate in healthy patients thought to be about one in 200,000 (4,5). Remarkable progress.

 

The Anesthesia Patient Safety Foundation was formed September 30, 1985, by Ellison Pierce with the help of many others. The efforts of the APSF (http://www.apsf.org/) have produced this remarkable transformation in the patient care environment which arose initially in the operating room, and now is spreading to general medical/surgical/pediatric floors, emergency departments, and intensive care units. The accomplishments of the specialty of anesthesiology in advancing patient safety have been so successful that it has been emulated by other medical specialties and the patient safety movement has morphed into a multidisciplinary national safety patient foundation (http://www.npsf.org/) which will undoubtedly address many of the patient safety issues that are now recognized as widespread outside of operating rooms. Indeed, the notion of patient safety started by these visionaries has now infected the culture of medicine and it is now the buzz word of quality improvement programs everywhere. However, there is still a remaining problem with health care practitioners following the “watch one, do one, teach one” mantra from the Flexner era and before, leading current visionaries to conceive and promulgate simulation as an educational tool to advance patient safety.

 

Simulation:  Simulation: a situation or environment created to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions. –definition taught at the Center for Medical Simulation…Cambridge, MA

1967. Red Cross first aid classes teach a fairly recently described new CPR method, having discarded the chest pressure-arm lift method, the primary resuscitation method of the 50s and 60s and perhaps before. So what did we practice our CPR on? Resusci-Anne!…at that time a relatively new Laerdal product which was used everywhere to teach mouth-to-mouth and chest compressions following the contemporary recommendations of the American Heart Association. By today’s standards this was a relatively primitive simulator, one which is still in use.

 However, perhaps the most sophisticated simulator of all, SIM-ONE, had already been demonstrated in the late 1960s by Steven Abrahamson, the Dean of Education at USC (6).  He and his co-workers developed a high fidelity simulator; more sophisticated than the simulators currently available. It even fasciculated after injection of succinylcholine. However, it did require a room full of computers each with an attendant technician in the manner of a NASA space launch. Dr.  Abrahamson went on sabbatical, his simulator was dismantled, so the story goes, and it took advances in computer technology and the vision of subsequent simulation pioneers to result in the resurrection of this technology in the 90s. Simulation is now an exponentially growing field with the number of simulation centers in the 10s in the early 90s to now in 2007 there being certainly over 1,000 simulation centers worldwide.  Anesthesiologists have been early pioneers in simulation.  However, the surgical RRC has mandated simulation in the surgical curriculum, which the anesthesia RRC has not done.  Surgeons are emerging as equally important leaders now pushing simulation into high tech procedural areas.

 

Above excerpted from my intro (before the copy editors got their hands on it) to the just published

New Vistas in Patient Safety and Simulation, An Issue of Anesthesiology Clinics

 

1. MoorheadJJ: Surgical experience at Pearl Harbor  Journal of the American Medical Association 1942; 118:712-714.

2. BeecherHK: Anesthesia for men wounded in battle. In: Coates JB, De Bakey MF. Surgery in World War II Medical   Department United StatesArmy 1955; 2:70-74.

3. Bennetts FE: Thiopentone anaesthesia at Pearl Harbor. British Journal of Anaesthesia 1995; 75:366-368.

4. Eichhorn JH: Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology 1989; 70:572-7.

5. Lagasse RS: Anesthesia safety: Model or Myth? Anesthesiology 2002; 97:1609-1617.

Comments

[rlbates]

Nice post. I am old enough to have heard the comment "blood's dark" a few times in training. Glad I never have to say it myself. Thanks to you guys at the head of the table.

[kofke]

so given this contractors compulsion to comment on an article ina series of articles which include one emphasizing application of pareto economics to a successful clandestine way to decrease quality one can only assume that this contractor is fully aboard with the concept leading one to wonder about the materials that are hidden behind the walls of whatever it is that they are building. thus their houses may appear safe but judging the manner in which they choose to do shotgun posts on unrelated blogs one also has to wonder how much attention is given to the quality of their work.